The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

STRONG MEMORIAL HOSPITAL 601 ELMWOOD AVE ROCHESTER, NY 14642 Jan. 7, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on medical record review and document review, staff did not ensure a restraint order was obtained for 1 of 5 patients. Not obtaining an order for restraints could result in inadequate patient assessment relative to patient condition and need for restraint.

Findings include:

Review of the medical record for Patient B dated 11-22-15 at 5:15pm revealed 4 point restraints were applied and discontinued at 7:30pm with no documentation to indicate an order for restraint usage was obtained.

Review of Strong Memorial Hospital Policy Section 10. Patient/Public Health & Safety 10.2.1 Restraints and Seclusion for Violent/Self -Destructive Behaviors last reviewed 6-13 revealed that following the face to face evaluation, the provider writes an order for the use of restraint or seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on medical record review and document review revealed no documentation of restraint discontinuation for 1 of 5 patients. This documentation laspse could result in staff being unclear as to the patient's restraint status.

Findings include:

Review of the Restraint Summary flowsheet for Patient B dated 11/23/15 revealed 4 point restraints were applied at 1:54am and continued as of 3:45am. However, there is no clear documentation as to when they were discontinued.
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Review of Strong Memorial Hospital Nursing Practice Procedures & Polices Manual Section 5, Documentation/Assessment last reveiwed 10/22/14 revealed nursing is to document the application and discontinuation of patient restraints in the medical record.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on document review, observation, and interview, the hospital did not conspicuously post a copy of the Parent's Bill of Rights as required by New York State regulation in Title 10 New York Codes, Rules and Regulations (NYCRR) 405.7(d) in areas where pediatric patients are located.

Findings include:

Review of facility policy #11.01.1 "Patient's Rights and Responsibilities" (dated 3/10/15) revealed that a Parents' Bill of Rights and Responsibilities will be posted in a conspicuous place.

Observation during tour of the pediatric intensive care unit on 1/6/16 at 11:15 AM, and of the pediatric emergency department on 1/6/16 at 12:30 PM, revealed no posted copies of a Parent's Bill of Rights on the units. This was confirmed at the time of the pediatric intensive care unit tour by Staff #1, 3 and 17, and at the time of the pediatric emergency department tour by Staff #1, 3 and 10-12.